Updated 7 October 2022
We carried out this announced comprehensive inspection on 13 September 2022 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered practice was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The dental clinic was visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance; however, these were not always followed.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The dental clinic had information governance arrangements, however not all audits had documented learning points.
Background
The provider has 7 practices and this report is about JDRM Dental Care Loughborough. JDRM Dental Care Loughborough is in Loughborough and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with additional needs. Ground floor reception, waiting area and treatment rooms are available as well as a disabled access toilet.
The dental team includes 6 dentists, 7 dental nurses, including 3 trainee nurses, 4 receptionists and a practice manager. The practice has 4 treatment rooms.
During the inspection we spoke with 1 dentist, 3 dental nurses, 2 receptionists, the practice manager, the operations manager, and the company directors, one of whom is also the registered manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Sunday from 8am to 8pm.
The practice had taken steps to improve environmental sustainability. For example, a member of staff is the designated energy champion. They look at ways to help practices within the group be more environmentally sustainable. This includes reducing carbon footprint by use of LED lights, turning off lights and computers when not needed, recycling, bulk ordering items from delivery companies to reduce the number of journeys to the practice. Recruiting staff from the local area wherever possible. Directors meetings are being held by zoom to try and reduce travel to meetings. A competition was held at Christmas which encouraged staff to upcycle items to make Christmas decorations for the practice.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular ensure diamond burs and cotton wool is correctly stored in each treatment room.
- Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records. Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Take action to ensure audits of radiography are undertaken at regular intervals to improve the quality of the service. Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.